Opinion

More research needed to address complex questions raised by take-home naloxone

Although providing take-home naloxone to people who consume opioids and their peers is considered by many researchers, service providers and others to be an exemplary harm-reducing intervention, uptake remains minimal in Australia. Seemingly a straightforwardly positive health intervention, the provision of take-home naloxone actually entails a range of complex proposals about individual responsibility, community knowledge and social dynamics, in a context that remains reliant upon a criminalisation framework. Research has yet to consider closely these proposals and their effects, in particular, little research has actively considered take-home naloxone’s implication in broader public health approaches that focus on individual behaviour change to address harms that might otherwise be seen as socially and politically produced.

Background

The last decade has seen worldwide increases in the consumption of heroin and pharmaceutical opioids (1), including in Australia (2). Alongside increases in consumption can be found increases in rates of opioid overdose both worldwide (1) and in Australia where accidental deaths due to opioid consumption have been steadily increasing since 2005 (3). A great deal of research now shows that the provision of take-home naloxone saves lives (4-10). Small scale take-home naloxone programs have commenced in all but two Australian jurisdictions (11), and the scheduling of naloxone in Australia has changed recently too, moving from prescription-only availability to ‘over-the-counter’ availability (12). Despite these measures, however, impediments to uptake and diffusion of take-home naloxone remain (e.g. 13-15).

Consumer attitudes to take-home naloxone

While some opioid consumers demonstrate willingness to participate in overdose response training and administer naloxone to their peers (16-21), it is also thought that some actively choose not to engage with it (11). The research conducted to date indicates that deterrents to uptake include fears of stimulating withdrawal symptoms (22, 21), fears of police involvement (17, 20, 21), preference for ‘home remedies’ (23) and feeling burdened by the responsibility to attend upsetting overdose events (22, 24). The mode of naloxone administration available also appears to be important in that consumers sometimes express a preference for intranasal administration (25). Importantly, some research also suggests that successful administration of naloxone in an overdose event can enhance self-esteem and a sense of having a valuable community role (26).

Health professionals’ attitudes to take-home naloxone

Scholarship on the attitudes towards take-home naloxone of health professionals also presents a complex picture. Research points to concerns about take-home naloxone acting as a ‘safety net’ that might encourage the consumption of high doses of opioids (27, 28) and questions have been asked about the capacity of people who inject drugs to properly identify an overdose and administer naloxone (27, 29). Such concerns reproduce unexamined assumptions about the agency and capacity of people who consume drugs (30, 31) and remind us that stigma remains highly relevant to the success or otherwise of health interventions concerning alcohol and other drugs, especially opioid consumption (32). That said, recent Australian research with alcohol and other drug service workers highlights strong support for take-home naloxone provision (14).

Questions raised by sociological research on take-home naloxone

The complexity of the interpersonal and social issues surrounding take-home naloxone suggest the need for more sociologically informed research. To date, very little research of this kind has been conducted. The work that has been done emphasises the importance of combining take-home naloxone provision with interventions into broader harm producing forces such as unemployment and poverty. According to McLean (33), for example, a need remains to think beyond the individual and to tackle the other forces that contribute to overdose if harm reducing and lifesaving opportunities are to be fully exploited. Other researchers argue that take-home naloxone has managed to find acceptance where it has partly because it incorporates the individualising tendencies of contemporary public health policy (34). Relying on opioid consumers’ local knowledge of overdose, consumption practices and social networks, positions consumers trained in the administration of naloxone as local health workers with important expertise and the ability to positively contribute to the community. This potentially de-stigmatising subject position has many benefits (34) but, it might be argued, can come at the cost of broader approaches that seek change beyond individuals and their willingness and ability to intervene in overdose events. This tension between individual responses and larger social responses, between the recognition of local and global forces in producing overdose events, is one of several issues that remain to be thoroughly researched using appropriate methods and concepts. Other key areas that would benefit from further research include:

the affective dimensions of overdose and naloxone administration, and the impact of attending overdose events in a responsibilised role;

experiences of training in the use of take-home naloxone, including the ways in which overdose is presented, risk is discussed and the trainees’ status as opioid consumers is managed;

the potential for take-home naloxone provision and training to interrupt or reinforce stigmatising assumptions about people who consume opioids;

the embeddedness of the role and effects of take-home naloxone in peer social networks, and the implications this network model of effectiveness has for promoting uptake in equitable and sustainable ways.

A new research project, which began in April this year at the National Drug Research Institute’s Melbourne office with funding from the Australian Research Council (Understanding the impediments to uptake and diffusion of take-home naloxone in Australia), takes up these challenging questions, seeking to emphasise the importance of social forces, power and inequality in ways analyses of take-home naloxone have yet to do. Its aim is to allow a fuller understanding of how take-home naloxone can shape, and in some cases benefit, the lives of those who consume opioids, along with its relation to the politics of alcohol and other drug responses.